Journal of Biomedical Informatics 42 (2009) 748755

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Journal of Biomedical Informatics

journal homepage: www.elsevier.com/locate/yjbin

Methodological Review

Health GIS and HIV/AIDS studies: Perspective and retrospective

Rashmi Kandwal *, P.K. Garg, R.D. Garg
Geomatics Division, Department of Civil Engineering, IIT Roorkee, Roorkee 247667, Uttarakhand, India

a r t i c l e

i n f o

Article history:
Received 17 October 2008
Available online 6 May 2009
Keywords:
GIS
Applications
Softwares
HIV/AIDS
Epidemiology
Health
Mapping
Surveillance
Modeling
Indian scenario

a b s t r a c t
GIS (Geographic Information System) is a useful tool that aids and assists in health research, health education, planning, monitoring and evaluation of health programmes that are meant to control and eradicate certain life threatening diseases and epidemics. HIV/AIDS is one such epidemic that poses a serious
challenge and threatens the overall human welfare. This communication is an attempt to link and understand the health scenario in a GIS context with emphasis on HIV/AIDS. Various GIS based functionalities
for health studies and their scope in analyzing and controlling epidemiological diseases are explored.
Overall scenario of the spread of HIV/AIDS around the world is presented along with the Indian perspective. Finally, we conclude with the general management problems, issues and challenges related to HIV/
AIDS prevailing in India.
2009 Elsevier Inc. All rights reserved.

1. Introduction
Health is vital for all of us and understanding the determinants
of a disease, its spread from person to person and community to
community has become increasingly global [1]. As expressed by
Scholten and De Lepper [40], health and ill-health are affected
by a variety of life-style and environmental factors, including
where people live. There are various factors such as climate, environment, water quality and management, education, air pollution,
natural disasters, social and many others which are the reasons for
the emergence of diseases as shown in Fig. 1 (also known as the
The Dahlgren-Whitehead model). The characteristics of these locations (including socio-demographic and environmental exposure)
offer a valuable source for epidemiological research studies on
health and the environment.
Epidemiological research ranges from outbreak investigation,
data collection, design and analysis including the development of
statistical models. Since health is a geographical phenomenon
and various factors attributing to the health diagnostics and planning are geography dependent, as such, GIS (Geographic Information System) for health studies serves as an important tool. GIS
can be useful for health researchers and planners because it plays
a vital role in strengthening the whole process of epidemiological
surveillance, information management and analysis. It serves as a
common platform for convergence of multi-disease surveillance
* Corresponding author. Fax: +91 0133 2285462.
E-mail address: rashmi.kandwal@gmail.com (R. Kandwal).
1532-0464/$ - see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jbi.2009.04.008

activities. The standardized geo-referencing of epidemiological

data facilitates structured approaches to data management. Once
the basic structure is ready, it is easy to convert it to surveillance
system for any other study. Public health resources, specic diseases and other health events can be mapped in relation to their
surrounding environment and existing health and social infrastructures. GIS is being used by public health administrators and
professionals, including policy makers, statisticians, regional and
district medical ofcers [44]. Some of its applications in public
health are: (1) geographical distribution and variation of diseases
(2) analysis of spatial and temporal trends (3) identifying gaps in
immunizations (4) mapping populations at risk and stratifying risk
factors (5) documenting health care needs of a community and
assessing resource allocations (6) forecasting epidemics (7) planning and targeting interventions (8) monitoring diseases and interventions over time (9) managing patient care environments,
materials, supplies and human resources (10) monitoring the utilization of health centers (11) route health workers, equipments and
supplies to service locations (12) publishing health information
using maps, etc.
Health and ill-health therefore, always have a spatial dimension. More than a century ago, epidemiologist and other medical
scientists began to explore the potential of maps for understanding
the spatial dynamics of diseases. A study carried out by Dr. Snow,
[17] is often cited to show that the importance of spatial dynamics
in understanding of diseases, and the use of maps to describe and
analyze it, is not so recent [8]. Dr. Snow made the hypothesis that
cholera might be spread by the infected water supplies more than a

R. Kandwal et al. / Journal of Biomedical Informatics 42 (2009) 748755

749

Fig. 1. The Dahlgren-Whitehead model. Factors responsible for the world-wide emergence of diseases (adopted from The Future of the Publics Health in the 21st Century
[52]).

century ago using maps to demonstrate the spatial correlation between cholera deaths and contaminated water supplies in the area
of Soho in 1854. Scholten and Lepper [40] use the example of AIDS,
stressing the importance of spatial distribution of the disease,
which they say has been too often overlooked. Another study highlighted that modeling and spatial distribution of AIDS can contribute to both educational interventions and the planning of health
care delivery systems [19]. Mapping can play an important role
in both areas as it is an excellent means of communication. In order
to be of use to resource planners, prediction of AIDS should include
a spatial component. Looking into the spatial aspects of health augments the understanding of particular diseases of interest also
serves as means to plan interventions and help planners to take
important decisions [2,47]. It is interesting to study and analyze
the domain knowledge of GIS and statistics and integrate it with
medical science to understand the advances and gaps. It is being
widely used in public health, environmental health and epidemiological research in general. World Health Organization (WHO),
United Nations Childrens Fund (UNCF), US Center for Diseases,
United Nations Member States, Public Health Agencies of different
countries have been widely using GIS at large in epidemiology.

2. GIS for health

The representation and analysis of maps of disease incidence
data are basic tools in the analysis of regional variation in public
health. The development of methods for mapping disease incident
has progressed considerably in recent years. This growth in interest has led to a greater use of geographical or spatial statistical
tools in the analysis of data both routinely collected for public
health purposes and in the analysis of data found within ecological
studies of disease relating to explanatory variables. The study of
geographical distribution of diseases can have a variety of uses
and can t into any of the three classes [10]:
 Disease mapping usually the object of the analysis is to provide (estimate) the true relative risk of a disease of interest
across a geographical area. Application of such methods lies in
health service resource allocation.

 Disease clustering this aids in public health surveillance, to

decide where it may be important to be able to assess whether
a disease map is clustered and where the clusters are located.
The analysis of disease incidence around a putative source of
hazard is a special case of cluster detection.
 Ecological analysis this focuses on the analysis of the geographical distribution of disease in relation to explanatory
covariates, usually at an aggregated spatial level.
2.1. GIS operation
Generally, the objectives of GIS are the management (acquisition, storage and maintenance), analysis (statistical and spatial
modeling) and display (graphics and mapping) of geographical
data and hence producing meaningful results. The methods which
generally apply to health-related analyses using GIS include overlay analysis of thematic data and spatial intersection, buffer generation, neighborhood analysis, vector-based grid generation,
network analysis and raster surface modeling. These GIS methods
need to be coupled with proper spatio-temporal statistical methods to ensure valid analyses and robust conclusions [3]. It is a valuable tool to assist in health research, health education, planning,
monitoring and evaluation of health programmes and health systems [2]. At the basic level, GIS can provide map-based point
and click access to view information about a particular feature,
such as a district or facility, while more advanced users can employ
spatial analysis techniques to answer questions related to their
health-sector concerns accessing relevant data from a Data Base
Management System (DBMS) or Relational DBMS. DBMS is central
to GIS and contains two main types (more or less closely integrated
depending on the system); a spatial database containing location
data and describing the location of earths surface features (shape,
position), and an attribute database containing certain characteristics of spatial features.
Within the domain of spatial analysis techniques, the geographic boundaries of study areas can be accessed and modied,
data class intervals and symbologies restructured, map layers
(variables) vertically overlaid and integrated, new independent
map variables added for multivariate spatial statistical analysis,
spatial weights computed, spatial autocorrelation on predictor

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variables assessed, and probability scenarios of mapped variables

explored based on modeled changes in regression coefcients over
time, with unparalleled computational speed and ease. By creation
of buffer zones, it is possible to plan or investigate the occurrences
of diseases around important locations for which planning of new/
additional health facilities are required. The user can specify the
size of the buffer and then intersect or merge the information with
the disease incidence data to determine the counts of the illness
that fall within the zone. GIS also enable multi-dimensional surface
images to be drawn to scale, a feature important in studies involving elevation or subsurface shape. The mathematical treatment of
topographic or surface statistical values can be used as a lter
against other variables or other surfaces. A range of statistical techniques have evolved that are well suited to GIS analysis, including
density kernel estimation, grid and probability estimation, and kriging. Spatial statistics can be divided into (i) methods for point pattern analysis, (ii) methods for lattice data and (iii) geostatistics.
Lattice data are discrete spatial units that are not a sample from
an underlying continuous surface (geostatistical data) or locations
of events (point patterns). Of these, the geostatistical approach is
most relevant to epidemiological analysis conducted at the landscape scale which are usually regional phenomenon and are based
on remote sensing and GIS. Spatial statistical methods like spatial
autocorrelation, spatial pattern analysis and clustering account
for the spatial variation inherent in spatial data and can be used
for statistical inference. This spatial prediction can be based entirely on a stochastic model or in combination with a deterministic
trend [3,14,16,29,39,50,53].
Further, the analytical tools available within GIS make it possible to integrate a variety of factors that inuence the spread and
development of the disease. In particular, these factors relate to
census data, economic and socio-cultural characteristics of countries or regions that affect the pattern and development of such
diseases [3,24,31]. Economic factors include life expectancy, income, gender inequality, and labor mobility. Socio-cultural variables include education, religion, the ethnic composition of a
population and the type of living environment. Other factors are
the age of the epidemic, the types and availability of treatments
and sexual practices [31].
2.2. Temporal dimension
Time plays a major role in any type of medical analysis. So spatial analysis alone is not sufcient unless we incorporate the temporal dimension of variation into the study. Advanced spatial and
temporal epidemiological studies have been done by many
researchers using the concept of spatio-temporal cluster and statistical analysis [13,21,26,35,42]. The basic problems in geographical surveillance for a spatially distributed disease are the
identication of areas of exceptionally high prevalence, to test
their statistical signicance, and to identify the reasons behind
the elevated prevalence of the disease [42]. Temporal, spatial and
space time scan statistics are commonly used for disease cluster
detection and evaluation [20,43,45,48]. One theme which is of particular interest both to the medical community and to the GIS specialists is temporal animation. It is highly suitable for
implementation in a temporal GIS (TGIS) environment [28,36]. To
date, the development and implementation of geographical visualization (GVis) and TGIS has yet to be realized. The implementation
enables users to visualize the data and focus on what is relevant,
thereby transcending the presentational realms of visualization.
Implementing exploratory temporal animation is synonymous
with current work that seeks to integrate GVis, GIS and knowledge
discovery in databases (KDD) into comprehensive systems that
have interactive visual displays, temporal geospatial operations
and data mining capabilities [24,25]. Imbuing animation with do-

main intelligence is an area of study that has great signicance

for geo-applications dealing with disaster prevention, early warnings and emergency elds [4,5,24,36].
2.3. Data mining
Another challenge in the eld of medicine is knowledge discovery from the growing volume of data. Health-care is a knowledgeintensive domain in which neither data gathering nor data analysis
can be successful without using knowledge about both the problem domain and the data analysis process. Most of these applications are particular and involve individual machine learning
technique, such as data mining. Data mining, also known as
knowledge discovery in databases, is the process of discovering
interesting patterns in databases that are meaningful in decisionmaking and is also an application area that can provide signicant
competitive advantage to an organization [2325,32]. It is concerned with nding models and pattern from the available data.
Data mining includes predictive data mining algorithms, which result in models that can be used for prediction and classication,
and descriptive data mining algorithms for nding interesting patterns in the data, like associations, clusters and subgroups [25].
2.4. Location/allocation facilities and health services management
It is evident that many questions concerning the provision of
health care are related to space. People are distributed in space
and not evenly. Health problems vary in space and so do the needs
of the people. Location of health care centres and services offered
by these to cater the needs of populations varying in number,
dimension and densities can be addressed and resolved with spatial analysis tools. GIS is a relatively new and complex technology,
which explains why they have not been used to their full potential,
especially in the health domain where they are extremely promising. We are not at a point where their possibilities are more clearly
seen with developments in hardware and softwares. However, GIS
has been widely used for developing prototypes for health management, disease surveillance, disease control, facility management and other related aspects [5,6,11,13,18,47]. These health
information systems have different uses catering to the needs of
a wide audience ranging from medical practitioners, government
agencies, general public and the research fraternity. They help
the planners and decision makers to effectively plan the control
measures.
2.5. Software applications
Epi Info (www.cdc.gov/epiinfo), Health Mapper (www.
healthmap.org/en), ChildInfo (www.childinfo.org), SIGEpi (www.
paho.org), Research Analyst, SaTScan (www.satscan.org) are
some of the specially designed application packages for health
studies. Most of them are either open source under the GNUs General Public License (GPL) or freeware and are freely downloadable
via internet. They help in easy form and database construction,
data entry, and analysis with epidemiologic statistics, maps, and
graphs, revealing trends, dependencies and inter-relationships.
Estimation and Projection Package (EPP) is a relatively new software package used to estimate and project adult HIV prevalence
from surveillance data. While EPP can be used in all countries with
sufcient surveillance data, it is specically recommended for
countries with generalized epidemics (www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/epi_software2007.asp). Some
software like SIGEpi and Research Analyst disseminates the use
of GIS as a tool for analysis and problem-solving. The package offers simplied tools and interfaces to efciently carry out biostatistical and geographical analysis to support decision-making in

R. Kandwal et al. / Journal of Biomedical Informatics 42 (2009) 748755

public health. Such information when mapped together creates a

powerful tool for monitoring and management of disease and other
public health programmes. Other than these individual packages
the bigger players in the software industry, like ESRI ArcView,
ArcGIS (including ArcMap, ARC/INFO) for advanced users and ArcIMS, the Internet Map Server, basically used for web GIS
(www.esri.com), GRASS: a public domain software under the
GNUs General Public License (GPL) (http://grass.itc.it), AutoDesk
Map2000 (www.usa.autodesk.com) and Intergraph GeoMedia
(www.intergraph.com) provide individual health modules.
While the developed countries have taken initiatives to establish well organized GIS based health surveillance systems, the
developing countries are still facing increasingly diverse and complex problems mainly due to resource constraints and non-availability of reliable information about diseases and those affected.
In addition, the formulation of a proper GIS system faces some
constraints which include problems in having updated information from the eld, including delays, non-reporting, non-response
and generally, unsatisfactory quality of generated data from primary sources. With a proper availability of database, the analysis
in GIS extends the capabilities to analyze the information based
on their common geographic occurrences that makes GIS a very
valuable tool in understanding the health/disease related research. This analysis not only helps in understanding the reasons
for poor utilizations of health services, but also to plan the future
needs for improving the scenario [4,13,18,26,47].

3. HIV/AIDS: an overall scenario

Acquired immune deciency syndrome or acquired immunodeciency syndrome (AIDS) is a collection of symptoms and infections resulting from the specic damage to the immune system
caused by the human immunodeciency virus (HIV) in humans.
The late stage of the condition leaves individuals susceptible to
opportunistic infections and tumors. Most researchers believe that
HIV originated in sub-Saharan Africa during the twentieth century,
it is now a pandemic, with an estimated 38.6 million people now
living with the disease worldwide. As of January 2006, the Joint
United Nations Programme on HIV/AIDS (UNAIDS) and the WHO
estimate that AIDS has killed more than 25 million people since
it was rst recognized on June 5, 1981, making it one of the most
destructive epidemics in recorded history. An estimated 33 million
people were living with HIV in 2007 (Fig. 2).
There were 2.7 million new HIV infections and 2 million AIDSrelated deaths in the year 2007. The rate of new HIV infections has
fallen in several countries, but globally these favorable trends are
at least partially offset by increases in new infections in other
countries. Globally, women account for half of all HIV infections
this percentage has remained stable for the past several years.
The global percentage of adults living with HIV has leveled off
since 2000. In virtually all regions outside sub-Saharan Africa,
HIV disproportionately affects people who inject drugs, men who
have sex with men and sex workers [38].
In Asia, an estimated 5 million people were living with HIV in
2007. The number of new infections and people who died from
AIDS-related illnesses was 380,000 in 2007. Injecting drug use is
a major risk factor in several Asian countries. In some countries,
HIV prevalence has remained very low (less than 0.1 percent in
the 1549 year old population). HIV surveillance has found only
a few cases of HIV infection among female sex workers, male
STD (sexually transmitted diseases) clinic patients. In the Philippines, AIDS case reporting has slowly increased to a total of 8200
as of end of 2007. It is estimated that in China in 2006, slightly fewer than half the people living with HIV are believed to have been
infected through use of contaminated injecting equipment. Similar

751

scenarios are estimated to be occurring in parts of India, Pakistan

and Vietnam. Similarly, a small number of AIDS cases and low levels of HIV infection have been reported from Indonesia. Injectiondrug-use is an important factor in Myanmar, near Afghanistan
and Pakistan, and in major cities. HIV is also transmitted perinatally and through breast-feeding. When examined through the lens
of current national HIV prevalence and incidence rates, most other
countries in Asia and the Pacic would conform to a pattern of low
prevalence and slow HIV spread. It is estimated that 5.7 million
HIV-infected people are present in India as compared with 5.5 million in South Africa according to UNAIDS estimates of 2006 [41].
With more HIV infections than any other country in the world, India gives the impression that HIV infection is common and that
there is a severe epidemic in the country. However, a preliminary
analysis of the National Family Health Survey which was conducted under international supervision and with U.S. funding
suggests that India has between two million and three million people living with HIV/AIDS, according to several sources, including
U.S. epidemiologists and the Indian Ministry of Health and Family
Welfare. The survey concluded last year [51]. However, the estimated 2.5 million HIV infections should be considered in the context of more than 1 billion population of India. The prevalence of
HIV is about 0.3 percent, a rate much lower than many other countries in the Asia-Pacic region.
3.1. Indian scenario
According to a report by WHO, 2006 [46], the scenario of HIV/
AIDS in India is alarming and rapidly changing. It is the second
largest population in the world; the total population surpassed 1
billion in the year 2001 of which a total of 67% population lives
in rural areas and 33% in urban areas [12]. India has 35 states
and union territories, and over 600 districts. HIV infection is not
evenly distributed throughout the country and the infection is
actually highly localized [38] as shown in Fig. 3.
The rst case of HIV infection in India was reported in 1986. In
1987, HIV sentinel surveillance and AIDS case identication was
launched. Initially, HIV got spread among female sex workers
and their male clients, STI clinic patients, and professional blood
donors. It subsequently began to spread among populations
including women attending antenatal clinics. Steinbrook [41],
2007 presented a picture of the HIV/AIDS scenario quoting that
perhaps 85% of HIV transmission in India is through sexual contact.
India still has many paid blood donors; contaminated blood and
blood products account for about 2% of HIV infections. Accessing
complete, comparable data for all regions, states, union territories
and districts is a major challenge. HIV prevalence among sex
workers in India varies widely from state to state, with high HIV
prevalence in western and southern India to low levels of HIV in
eastern and northern India. In a few of Indias states, data show
high HIV prevalence among sex workers, and possibly rising HIV
prevalence among people who inject drugs and men engaged in
multi-sex practices. Although HIV has spread into the wider population and, in some states, is affecting increasing numbers of
women considered to be at low risk of infection, the countrys epidemic is largely a result of HIV transmission within, between and
immediately beyond those most-at-risk populations. Furthermore,
sex between men is a signicant, yet under-researched aspect of
Indias HIV epidemic [38]. Fig. 4 shows a time series plot of number
of people with HIV in India based on data from report on the
Global AIDS epidemic, 2008. According to earlier estimates,
(www.web.worldbank.org/) about 2.45 million Indians were living
with HIV with an adult prevalence rate of 0.41% in 2006 and among
almost 100,000 adults (aged 1549 years) tested for HIV in the
most recent national population-based survey [34], reported prevalence was 0.28%.

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Fig. 2. A global scenario of HIV/AIDS (adopted from report on global AIDS epidemic, UNAIDS, 2008).

The epidemic is largely concentrated in six Indian states in the

industrialized south and west, and in the north-eastern tip. On
average, HIV prevalence in southern states overall was about ve
times higher than in northern states in 20002004 [22]. Reported
adult HIV prevalence in six states included in the recent national
population-based survey [34] varied from 0.07% in Uttar Pradesh,
0.34% in Tamil Nadu, 0.62% in Maharashtra, 0.69% in Karnataka,
0.97% in Andhra Pradesh, to 1.13% in Manipur.
According to Indias National AIDS Control Organization (NACO)
(www.nacoonline.org/NACO), the bulk of HIV infections in India
occur during unprotected heterosexual intercourse. Consequently,
as the epidemic has matured, women account for a growing proportion of people living with HIV (38 percent in 2005), especially
in rural areas. The low rate of multiple partners concurrent sexual
relationships among the wider community seem to have, so far,
protected the larger body of people with 99 percent of the adult Indian population being HIV negative. However, although overall
prevalence remains low, even relatively minor increases in HIV
infection rates in a country of more than one billion people could
translate into large numbers of people becoming infected [49].
3.2. HIV/AIDS issues and challenges in India
While the governments response has been scaled up markedly
over the last decade, major challenges remain in raising the overall
effectiveness of various level programs, expanding the participation of other sectors, and increasing safe behavior and reducing
stigma associated with HIV-positive people among the population.
Several factors are responsible for the rapid spread of HIV if effective prevention and control measures are not scaled up. Below are
the major issues and challenges associated with HIV/AIDS research

which have been predominantly summarized from the World Bank

Report 2008 [49].
 Inadequate competence at the institutional level. These include the
institutional constraints, including structural and managerial,
temporal data collection and analysis to scale up at the national
and state levels. These factors should be addressed as the program expands its response to the epidemic in the direction for
a stronger multi-sector response for the next phase of HIV/AIDS
program. The states and Union Territories need to provide
implementation capacity to put a robust program into place.
There is a need for tailored capacity-building activities and
attention to performance-based nancing approaches [9,49].
 Benefactor synchronization. There is a need for better coordinating mechanisms among the benefactors to reduce the transaction costs since they have own mandate and requirements, as
well as areas of focus. The transaction cost to the government
as a result of attending to the various demands of the benefactors is huge [49].
 Effective decision making using available data/reports. There
remains a need for greater use of data for decision making,
including program data and epidemiological data. A lot of data
that are being generated is not adequately used for managing
the program or informing policies and priorities. Results-based
management and linking incentives to the use of data should
be explored [49].
 Stigma and discrimination. Stigma and discrimination against
people living with HIV/AIDS and those considered to be at high
risk remain entrenched. Stigma and denial undermine efforts to
increase the coverage of effective interventions among high risk
groups [9,37,49].

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5 000
4 000
3 000
2 000

20
06

20
04

20
02

Year

4. Research perspective: GIS and HIV/AIDS

HIV/AIDS epidemic has started to challenge recent developmental achievements and to raise fundamental issues of human rights
concerning people living with HIV/AIDS. The study conducted by
Mahal and Rao [30] is an intense review to elaborate on the major
elements of the national and international economic research to
data on HIV/AIDS, The study highlights the fact that very little
work on the inuence of HIV on technological progress exists at
present, except mainly through its impact on biomedical research.
Economics can contribute usefully to thinking about and measuring the potential impacts of the HIV/AIDS epidemic and in the
development of optimal strategies to address it.
As mapping is an excellent means of communication, GIS produces materials which are both useful and conducive to public participation in community health projects. From this, effects in
health domains are obvious. Sources of information about, and
examples of, mapping AIDS and representation of disease events
is provided by Smallman et al. [56] in their atlas. Visualization

20
00

19
98

19
96

19
94

19
92

1 000

19
90

 Low awareness. In a context of a severe gap of knowledge about

prevailing risk-taking sexual behaviors, creates great uncertainty about the future course and impact of the epidemics. An
appreciation of this fact is important in planning suitable interventions. New approaches need to be tried to reach communities with information about HIV/AIDS and how to prevent and
treat HIV/AIDS [9,49].

People living with HIV

Fig. 3. Adult (aged 1549 years) HIV prevalence in India states, Population-based survey, 2006 (adopted from: Report on Global AIDS Epidemic, 2008).

Estimated number of people living with HIV

Low estimate
High estimate
Fig. 4. Time series plot of the estimated number of people with HIV in India
(adopted from: Report on Global AIDS Epidemic, 2008).

which is the simplest application of GIS has been attempted to

understand the spatial spread of HIV/AIDS [57,58]. Similar approach was exemplifed on a temporal scale by Jones et al. [55].
GIS was used to map the number of HIV services in a given area
in order to understand access to prevention and health care
[59,60]. They also calculated the distance of the prevention center
from the highly infected regions, thus aiding in the decision making policy.
Spatial Data Infrastructure (SDI) can play a key role by designing spatial database for epidemics. This information may again

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be useful for analysis in a geographical context. Busgeeth and Rivett [6] designed and developed an HIV/AIDS database, which is
embedded in a Spatial Information Management System (SIMS).
SIMS can play a critical role in determining where and when to
intervene, improving the quality of care for HIV+ patients, increasing accessibility of service and delivering a cost-effective mode of
information. The study was carried out in a district in South Africa
which is experiencing an HIV/AIDS pandemic of shattering dimensions. The system functions as an information system containing
accurate HIV/AIDS and infrastructure data and support decisionmaking and management. The advantage of these methods in GIS
is that they can provide spatial information required by the government agencies to plan better intervention. On similar lines, an
open source management system has been proposed by Vanmeulebrouk et al. [61]. Given the resource constraints of the local government context, particularly in small municipalities, they
proposed that open source software should be used for the prototype system.
Modeling approaches have proven to be highly relevant in HIV/
AIDS studies that include either inductive/empirical models or
deductive/theoretical models. Similar spatial and temporal models
for AIDS cases in US have been developed by Casetti and Fan [7]
and Gould et al. [15] and are used for prediction. Loytonen [27]
did inductive modeling to study HIV diffusion in Finland. Dynamic
compartmental simulation model for Bostwana and India, was
developed by Nagelkerke et al. [54], to identify the best strategies
for preventing spread of HIV/AIDS. Nakaya et al. [33], attempted
spatio temporal modeling of the HIV epidemic in Japan by employing an estimation method that allows the inclusion of geographically varying parameters. This research discusses the earlier use
of trend model, epidemiological model and the micro-simulation
models for projection of the epidemic cases.
5. Conclusion
GIS supported by spatial data infrastructure and vibrant routine
health data can give planners valuable information to address the
issues related to HIV/AIDS and support monitoring, evaluation and
planning. GIS can also be used as an effective tool to manage and
monitor HIV/AIDS and related routine activities. As health is largely determined by spatial factors (including the socio-cultural
and physical environment, which vary greatly in space), it always
has an important spatial dimension. Like all powerful technologies,
GIS can be applied by practitioners versed in public health methodologies. It can certainly be a tool of prime importance to health research and education. The spatial modeling capacities offered by
GIS can help to understand the spatial variation in the incidence
of disease, and its covariation with environmental factors with
health care.
The facts and gures presented here for the Indian scenario
brings out that it is often misleading to consider a country as a
homogenous entity as far as HIV/AIDS is concerned. There is a
sharp increase in the estimated number of HIV infections that
could translate into large numbers of people becoming infected.
An understanding of epidemiological principles and methods is required to structure studies and interpret results for proper socioeconomic development at various levels of the society. GIS based
mapping is therefore necessary to generalize, symbolize, and classify data so that maps communicate effectively rather than distorting the data behind the map and can aid in combating with the
spread of the disease once the geographical incidence, trend of
spread and related social-economic-geographical features are
ascertained. An appreciation of this fact is important in planning
suitable interventions and effective measures for controlling the
epidemic.

Acknowledgments
We thank National AIDS Control Organisation (NACO), Ministry
of Health and Family welfare, Government of India, New Delhi for
providing the HIV data and Indian Institute of Technology, Roorkee
for nancial assistance and infrastructure support.
References
[1] ESRI White Paper. Enterprise GIS in health and social service agencies; 1999.
[2] Balaji LN. GIS in health. GIS Dev 2000;IV(6):1720.
[3] Boulos MNK. Towards evidence-based, GIS-driven national spatial health
information infrastructure and surveillance services in the United Kingdom.
Int J Health Geographics 2004;3(1).
[4] Avruskin GA, Jacquez GM, Meliker JR, Slotnick MJ, Kaufmann AM, Nriagu
Jerome O. Visualization & exploratory analysis of epidemiological data using a
novel space time information system. Int J Health Geographics 2004;3(26).
[5] Bashir F, Ikram T. Disease early warning system implementation. GIS Dev
2003;7(5).
[6] Busgeeth K, Rivett U. The use of a spatial information system in the
management of HIV/AIDS in South Africa. Int J Health Geographics 2004;3(13).
[7] Casetti E, Fan CC. The spatial spread of the AIDS epidemic in Ohio: empirical
analysis using the expansion method. Environ Plan A 1991;23:1589608.
[8] Colledge M, Maxwell H, Parker R, Morse DJ. Geographic information systems
(GIS) in general practice: a new tool for needs assessment. J Inform Prim Care
1996;7(11).
[9] Solomon S. Challenges in the management of the HIV disease in India, <http://
www.cgdev.org/doc/events/3.06.08/Challenges_in_the_Management_of_HIV_
Disease.pdf>; 2008 [accessed 22.02.09].
[10] Don de S, Lori JA, Pandu W. GIS for health and the environment: proceedings
(IDRC). Srilanka; 1995.
[11] Dhar Arti, Mapping of health facilities undertaken. The Hindu, 19 September,
online
edition,
<http://www.hinduonnetcom/2007/09/19/stories/
2007091953560400.htm>; 2008 [accessed 05.09.08].
[12] Ekstrand Maria, Garbus Lisa, Marseille Elliot. HIV/AIDS in India, AIDS Research
Institute: AIDS Policy Research Center, University of California, San Francisco.
<http://ari.ucsf.edu/ari/policy/countries.htm>; 2003 [accessed 05.06.08].
[13] Ahuai J, Peter B, Paul S, Jefsodelling A, Frank P. A GIS driven integrated real
time surveillance pilot system for national west Nile virus dead bird
surveillance in Canada. Int J Health Geographics 2006;5(17).
[14] Ghio LC, Mark Nueman, Abdulkadir, Attieg Ahmed. Health GIS tools and
applications informing decisions in Yemen. Map Middle East; 2005.
[15] Gould PR, Kabel J, Gorr WL, Golub A. AIDS: predicting the next map. Interfaces
1991;21:8092.
[16] Graham AJ, Atkinson PM, Dansonn FM. Spatial analysis for epidemiology. Acta
Tropica 2004;91:21925.
[17] John Snow. On the mode of communication of cholera. London: John Churchill;
1855.
[18] Johnson CP, Johnson J. GIS: a tool for monitoring and management of
epidemics. Map India 2001 Conference, New Delhi, February 2001. <http://
pfrlib.cdacindia.com/html/pdf/geom6.pdf>; [accessed 05.09. 08].
[19] Kabel, R. Predicting the next map with spatial adaptive ltering. In:
Proceedings of the fourth international symposium in medical geography,
Norwich, 1619, July 1990, Norwich, UK: University of East Anglia.
[20] Kulldorff M, Nagarwalla N. Spatial disease clusters: detections and inference.
Stat Med 1995;1:799810.
[21] Kulldorff M, Athas WF, Feuer EJ, Miller BA, Key CR. Evaluating cluster alarms: a
space time scan statistics and brain cancer in Los Alamos, New Mexico. Am J
Public Health 1998;88:137780.
[22] Kumar R et al. Trends in HIV-1 in young adults in south India from 2000 to
2004: a prevalence study. Lancet 2006;367(9517):116472.
[23] Kuo RJ, Li SY, Shi CW. Mining association rules through integration of
clustering analysis and ant colony system for health insurance database in
Taiwan. Expert Syst Appl 2007;33:794808.
[24] Koua EL, Kraak MJ. Geovisualization to support the exploration of large health
and demographic survey data. Int J Health Geographics 2004;3(12).
[25] Lavrac N et al. Data mining and visualization for decision support and
modeling of public health-care resources. J Biomed Inform 2007;40:
43847.
[26] Lian M, Warner RD, Alexander J, Dixon KR. Using Geographical information
systems and spatial and space time scan statistics for a population based risk
analysis of the 2002 equine West Nile epidemic in six contagious regions of
Texas. Int J Health Geographics 2007;6(42).
[27] Loytonen M. The spatial diffusion of Human Immunodeciency Virus Type 1 in
Finland, 19821997. Ann Assoc Am Geographers 1991;81:12751.
[28] Madzudzo PF. Exploratory visualization of temporal events in epidemiological
research: case study of the Black Death. Thesis (PhD). The Netherlands: ITC;
2007.
[29] Maantay JA, Ziegler J. Geographic information systems for the urban
environment. Redlands, CA: Environmental Systems Research Institute (ESRI)
Press; 2002.
[30] Mahal A, Rao B. HIV/AIDS epidemic in India: an economic perspective. Indian J
Med Res 2003;121:582600.

R. Kandwal et al. / Journal of Biomedical Informatics 42 (2009) 748755

[31] Moran D, Jordaan JA. HIV/AIDS in Russia: determinants of regional prevalence.
Int J Health Geographics 2007;6:22.
[32] Mullinsa et al. Data mining and clinical data repositories: insights from a
667,000 patient data set. Comp Biol Med 2006;36:135177.
[33] Nakaya T, Nakase K, Osaka K. Spatio-temporal modeling of the HIV epidemic in
Japan based on the national HIV/AIDS surveillance. J Geographic Syst
2005;7:31336.
[34] National Family Health Survey (NFHS-3). Mumbai, India: International
Institute for Population Sciences; 2007.
[35] Odio A et al. Investigation of clusters of giardiasis using GIS and spatial scan
statistic. Int J Health Geographics 2004;3(11).
[36] Ogao PJ. A tool for exploring space time patterns: an animation user research.
Int J Health Geographics 2006;5(35).
[37] Fredriksson-Bass, Jenni, Kanabus Annabel. HIV and Aids in India. <http://
www.avert.org/aidsindia.htm>; 2006 [accessed 10.12.08].
[38] Report on the Global AIDS Epidemic. UNAIDS: Joint United Nations Programme
on HIV/AIDS. <http://viewer.zmags.com/publication/ad3eab7c#/ad3eab7c/1>;
2006 [accessed 24.02.09].
[39] Sanaei-Nejad SH, Sabokbar HAF. Developing health geographic information
systems for Khorasan Province in Iran. GIS development. http://
www.gisdevelopment.net/application/health/overview/me05_006.htm; 2007
[accessed 05.09.08].
[40] Scholten HJ, De Lepper MJC. The benets of the application of Geographic
information systems in public and environmental health. WHO Stat Quart
1991;44(3).
[41] Steinbrook R. HIV in India a complex epidemic. The New England J Med
2007;356:11.
[42] Tiwari N, Adhikari CMS, Tiwari A, Kandpal V. Investigation of geospatial
hotspots for the occurrence of TB in Almora district, India, using GIS and
spatial scan statistics. Int J Health Geographics 2006;5(33).
[43] Turnbull BW et al. Monitoring for clusters of diseases: application to leukemia
incidence in upstate New York. Am J Epidemiol 1990;132(1):13643.
[44] Weekly epidemiological record. Geographical information systems (GIS):
mapping for epidemiological surveillance, vol. 74(34). Geneva: WHO; 1999.
p. 2815.
[45] Wheeler DC. A comparison of spatial clustering and cluster detection
techniques for childhood leukemia incidence in Ohio, 19962003. Int J
Health Geographics 2007;6(13).

755

[46] WHO report. Update: epidemiological fact sheets on HIV/AIDS and sexually
transmitted infections, India; 2006.
[47] Yalagi A, AnbarasanV, Malipatil C Patil HD. HIV/AIDS Infection intervention
by using GIS as a tool, map world forum. <http://www.gisdevelopment.net/
application/health/planning/mwf_95abs.htm> [accessed 05.09.08].
[48] Yiannakoulias N, Rosychuk RJ Hodgson J. Adaptations for nding irregularly
shaped disease clusters. Int J Health Geographics 2007;6(28).
[49] World Bank Report. <http://www.worldbank.org>; 2006 [accessed 05.09.08].
[50] Anselin L, Exploring sptial data with Geoda: a workbook. <http://
geodacenter.asu.edu/system/les/geodaworkbook.pdf> [accessed 05.11.08].
[51] Medical news today, Number of HIV/AIDS cases in India might be lower than
current estimates, survey says. <http://www.medicalnewstoday.com/articles/
73851.php> [accessed 02.02.09].
[52] The future of the publics health in the 21st century. Washington, DC: The
National Academies Press; 2002. <http://books.nap.edu/openbook.php?
record_id=10548&page=R1> [accessed 22.02.09].
[53] Cromley EK, McLafferty SL. GIS and public health. UK: The Guilford Press;
2002.
[54] Nagelkerke NJD, Jha P, de Vlas SJ, Korenromp EL, Moses S, Blanchard JF, et al.
Modelling HIV/AIDS epidemics in Botswana and India: impact of interventions
to prevent transmission. Bull World Health Organ 2002;80(2).
[55] Jones W, McDonald P, Enright D, Sampson L. Using spatial statistics to describe
HIV morbidity in 3 North Carolina Counties. Atlanta, Ga: National HIV
Prevention Conference; 2003. Abstract no. TP-087.
[56] Smallman-Raynor MR, Cliff AD, Haggett P. Atlas of AIDS. Oxford,
England: Blackwell; 1992.
[57] McLafferty SL. GIS and health care. Ann Rev Public Health 2003;24(1):2542.
[58] Fulcher C, Kaukinen C. Mapping and visualizing the location HIV service
providers an exploratory spatial analysis of Toronto neighborhoods. AIDS Care
2005;17(3):38696.
[59] Law DCG, Serre ML, Christakos G, Leone PA, Miller WC. Spatial analysis and
mapping of sexually transmitted diseases to optimise intervention and
prevention strategies. Sex Transm Inf 2004;80(4):2949.
[60] Pillay R, Using GIS to spatially portray the prevalence of HIV/AIDS and some
demographic consequences in The Northern Province, South Africa:
International Conference on AIDS; 2002. 14: Abstract no. E11534.
[61] Vanmeulebrouk B, Rivett U, Ricketts A, Loudon M. Open source GIS for HIV/
AIDS management. Int J Health Geographics 2008;7:53.